In a nutshell, the ECD defines the data elements that are essential to be documented for a patient within the EHR so the care team may provide quality care. Currently there is little or no input from the public health field for several reasons. Report to the HHS Data Council on the viability of these elements and definitions being adopted in their program. Washington, D.C. 20201, U.S. Department of Health and Human Services, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Collaborations, Committees, and Advisory Groups, Physician-Focused Payment Model Technical Advisory Committee (PTAC), OS-Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, Core Health Data Elements: Report of the National Committee on Vital and Health Statistics. The currently recommended coding instrument is the ICD-9-CM. The NCVHS recommends continued monitoring of provider practices with regard to coding and revision of these recommendations if current guidelines continue to be ignored. Operating Clinician Identification - The unique national identification number assigned to the clinician who performed the principal procedure, as recommended by the UHDDS. Compelling evidence presented by the Indian Health Service, states and nonprofit organizations demonstrates that effective intervention strategies can be implemented in response to available data on external causes of injury. State of Kansas Department of Health and Evironment, Renate E. Pore Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. 9. B.The health care practitioner for each clinical service received by the patient, including ambulatory procedures. To transmit electronic data C. To create a process for transmitting data to external users D. Describe each data set . Paul Y. Ertel, M.D. Directorate of Medical Programs and Resources, Office of the Surgeon General, Frank J. Chaloupka An inpatient admission begins with the formal acceptance by a hospital of a patient who is to receive health care practitioner or other services while receiving room, board, and continuous nursing services. Dave Baldridge Department of Veteran's Affairs (19), Lora Kraus In addition, a number of elements for which consensus is close, must be field tested to confirm their definitions and collectibility. What are the Root Operations? American Physical Therapy Association, Anthony J. It also includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider. National Center for Health Statistics, Walter P. Bailey Health Care Finance Commission, Policy, Research and Data Management, Joanne Yancey Hitchcock A presentation by AHCPR reported on a study of 10 state data organizations and two statewide hospital associations participating in the Healthcare Cost and Utilization Project (HCUP-3). Centers for Disease Control and Prevention. Disposition of Patient (inpatient) 1/, 40. Randall Spoeri, Ph.D. Provide stable resources to the project to establish an interdepartmental work group, with DHHS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. California Department of Health Services, J. Henry Montes Administration for Children and Families, Susan N. Postal A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc. Health Care Financing Administration, Christine Rice Oak Orchard Community Health Center, Geraldine Nicholson University of California. Elliot M. Stone, M.V.C. Diagnosis Chiefly Responsible for Services Provided (outpatient), 38. Systems may also choose to collect other identifiers (e.g., tax number), which they can link to the NPI. The Committee's efforts, first in the area of inpatient hospital data (the Uniform Hospital Discharge Data Set or UHDDS) and later in the area of ambulatory care (the Uniform Ambulatory Care Data Set or UACDS) have moved the country in the direction of achieving comparability in the health data collected by federal agencies, states, localities and the private sector, as well as in the international community. Data elements used in UACDS are provider Identifications, address, type of practice, which includes the full name of the provider as well as the unique physician identification number (UPIN). In addition to the presentations at the meetings, more than 100 written responses to the solicitation letter were reviewed and considered. Because the full residential address could serve as a proxy personal identifier, confidentiality of the complete information must be safeguarded in public use of the data. Years of schooling has been found to be highly predictive of health status and health care use. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping? U.S. Department of Health and Human Services It is anticipated that the introduction of ICD-10 will alleviate this problem. Substance Abuse and Mental Health Services Administration, Stephen E. Marcus, Ph.D. APHA American Public Health Association, Katherine M. McCormack The currently recommended coding instrument is the ICD-9-CM. Division of Adolescent Medicine, Department of Pediatrics, David W. Emmons, Ph.D. If a reporting entity is using a different element or definition, explain why their current usage is preferable. Attending Physician Identification (inpatient), 22. IM System, David Newman, M.D. Center for Mental Health Services, Corinne Kirchner, Ph.D. Throughout the meetings it became apparent that many standards-setting groups are moving ahead without broader input, for example, from those in the public health and epidemiology fields. A recent Bureau of Labor Statistics study found that only 1.5 percent of respondents will choose the multiracial category. However, there is some evidence that the number of interracial marriages is accelerating. Shortly after arrival in the ER, the patient's. 11. Race and ethnicity B. As recommended by the UHDDS and the UACDS. Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis. of Socioeconomic and Practice Issures, American Academy of Dermatology, Harold S. Luft, Ph.D. Multiple responses are possible. Previous experience indicates that at least some, if not many, of these data items have differing definitions. Carries a procedural risk, or. Injury Related to Employment - Yes, No. While reviewing the draft list of data elements, respondents indicated a number of additional data elements that they felt were important core elements. 1. Performance monitoring and outcomes research are two additional areas that are currently hampered by the inability to link data sets from various sources due to varying data elements and definitions. medical and surgical care provided to patients who depart from the facility on the same day they receive care (outpatient). Which of the following data elements is unique to UACDS A. Operating Clinician Identification (inpatient) 1/, 23. Managed Behavioral Health News, Melvin Sabshin, M.D. Standard electronic formats are recommended to the extent that they have been developed. In the early 1990's, it formed an Ad Hoc Work Group on Confidentiality to study issues related to confidentiality, unique personal identifiers and data linkage across time and systems. The MDS system collects data on the physical, psychological, and psychosocial functioning of all residents of long-term facilities certified by Medicare or Legal Services of Middle Tennessee, Leonard Bourget 31. In addition, information was solicited by the NCVHS through two large-scale mailings, and public meetings were held with agencies and organizations which are currently collecting health data sets. A chart showing the distribution of all respondents to this second mailing by type of organization is shown in appendix G. The importance of participating in meetings of the various standard-setting groups has been recognized by the Committee. 3 is required; however NCVHS strongly advocates a single procedure classification for inpatient and ambulatory care. State of Washington Department of Health, Maria Rey Office for Civil Rights, DHHS, Patricia B. Merryweather, M.A. Performance monitoring and outcomes research are two areas that are currently hampered by the inability to link data sets from various sources. Facility Identification - The unique HCFA identifier as described above. National Perinatal Information Center, Mark J. Segal, Ph.D. prison), Principal diagnosis of an injury or poisoning. The increasing use of electronic data, the evolving managed care field, and the growing requirement for performance monitoring and outcomes research have made it imperative that all health data collection activities, where possible, utilize standardized data elements and definitions. It appeared that some types of data linkage could be obtained in states with smaller populations, but might not work nationwide. Core Health Data Elements Project A number of scales have been developed that include both a) self-report measures, such as the listings of limitations of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) and the National Health Interview Survey age-specific summary evaluation of activity limitations, and b) clinical assessments, such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH) and the Resident Assessment Instrument (RAI) (widely used in nursing homes). American Foundation for the Blind, Harvey A. Schwartz, Ph.D. Maine Health Information Center, Florence B. Fiori, Dr.P.H. The Committee has chosen to include these elements because it believes that the need for the type of information they contain will continue to increase. Department of Public Health, Dan Rode Why such data sets are needed in the current and evolving health care arena; What multiple functions they might accomplish for a variety of different users; What data elements (including definitions, vocabularies and coding structures) they might contain; and. Type of Facility/Place of Encounter 1/, 19. Principal diagnosis is required by most systems for inpatient reporting. The National Committee on Vital and Health Statistics (see appendix A for roster) has completed a two-year project requested by the Department of Health and Human Services to review the current state of health-related core data sets; obtain input on their collection and use; interact with data standards-setting groups; and, most importantly, promote consensus by identifying areas of agreement on core health data elements and definitions. The Committee's goal has been to develop a set of data elements with agreed-upon standardized definitions that, when needed in a data collection effort, can be used to collect and produce standardized data. ICD-10-PCS code for: 1. California Public Health Foundation, NAACCR, Maria Redona Couper, Ph.D., RN Patient's Stated Reason for Visit or Chief Complaint (outpatient). Another issue was the role of the National Committee itself as the source of information on common data elements. The NCVHS Subcommittee on Ambulatory and Hospital Care Statistics commented in the 1994 UACDS revision that years of schooling completed is the most feasible socioeconomic element to collect in the UACDS. This listing should be reviewed by the NCVHS and standards organizations and, if found acceptable, recommended for use. Bureau of Vital Records and Health Statistics. OMB is currently investigating the possibility of changes to this classification, and the Committee will await the OMB recommendations. The Committee supports the HHS Data Council in its formation of the Health Data Standards Committee to focus attention on the needs for standardized data both within the Department and in the health care community at large and to foster collaboration and consensus with the major standards-setting organizations. The Committee has appointed a liaison to participate in selected meetings of the American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X-12, a private sector coalition that is developing transmission standards for health data. Thomas P. Gross, M.D., MPH Health Insurance Association of America, John I. Gallin, M.D. 6. Uniform Ambulatory Care Data Set. Because the PAYERID system is still being developed, and because HCFA currently has no plans to categorize payers, the Committee recommends the current UHDDS categories while encouraging continued study and evaluation of categories used by other data collectors. Capture of the full four-digit year of birth is recommended 03. Concurrent with these activities being undertaken by the full Committee, there are two related projects undertaken by the Subcommittee on Mental Health Statistics and the Subcommittee on Disability and Long Term Care Statistics. National Center for Health Statistics. HHS, CDC, NIOS&H - ALOSH, Division of Safety Research, Kris Haltmeyer National Committee for Quality Assurance, James S. Todd, M.D. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. The database will contain payer names, billing addresses and business information. The UHDDS currently in use was promulgated by the Department in 1985; the NCVHS recommended and circulated a revision in 1992, with additional recommendations from an Interagency Task Force in 1993. For the first 12 elements, with the exception of unique identifier, information may not need to be collected at each encounter. ANSI ASC X-12 (Accredited Standards Committee), WEDI (WorkGroup on Electronic Data Interchange). This project has brought together efforts from several state agencies, including education (for the school data), agriculture (the source of WIC data in some states), as well as health departments. Each encounter generates a date of service that can be used to link encounters for the same patient over time. Admission Date (inpatient)- Year, month, and day of admission as currently recommended in the UHDDS and by ANSI ASC X12. These elements apply to persons seen in both ambulatory and inpatient settings, unless otherwise specified. Personal Identification The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution. The data is collected on inpatient hospital discharges for Medicare and Medicaid programs. New Hampshire Division of Public Health Service, Robert Roscoe The intent is not to specify a data set for mandated external reporting; the list of recommended data elements is by no means exhaustive, and, unlike earlier activities, is not a "data set" to be used in a specific setting. It will do so by assigning a unique identifier to each provider. University of Nebraska Medical Center, Deborah M. Nadzam, Ph.D., R.N. For those data elements which have been recognized as significant core elements, but for which there is not consensus on definition, support the formation of a public-private working group to conduct or coordinate additional study or research and to further refine definitions. It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. We realized that the industry needed a standardized dataset that provides essential elements for EHR documentation. In recent years, the Committee has recognized the importance of electronic standardization efforts which are taking place in the business community. The Committee recognizes that not all providers are obtaining this detail, but it is anticipated that these data will be more frequently collected in the near future with the growth of computerized prescription information. National Institute of Dental Research, NIH, T. J. Mathews There has been substantial agreement on data elements in these sets, but less agreement on data definitions. One would be through the use of a state-level or regional-level organization that already has a line of communication with other organizations. 10. [Uniform Ambulatory Care Data Set (UACDS)]: A core set of data elements used to report ambulatory data elements in standardized manner. The Committee recognizes the importance and desirability of linking services with diagnoses, wherever feasible. 1. National Highway Traffic Safety Administration, Amy Fine Center for Health Policy Studies, Rachael Block Public and private participants have indicated a willingness to work together to disseminate information, test data elements, and utilize electronic means to ensure the widest dissemination of these activities. Other Diagnoses (inpatient) - As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. 23. The American Academy of Family Physicians, Barbara Faigin Such a system would be helpful to the extent that it is feasible in the current highly dynamic market. American Psychiatric Association, Thomas C. Sawyer In August 1994, the Department recognized the National Committee's unique history in promoting standardization of health information when it asked the Committee to provide information and advice that will help maximize the utility of core person and encounter data for meeting the Department's responsibilities. The instruction clarifies that only what is known to the highest level of specificity should be reported. Additional evaluation and testing are warranted for this important information. The Committee feels that, over time, there will be increasing attention focused on this item and reaffirms its recommendations in the 1994 revisions to the UACDS that additional study and evaluation be conducted on the feasibility and utility of collecting and periodically updating information on a person's occupation and industry. Which data is collected on Medicare and Medicaid patients? What does ambulatory care include? Based on the compendium effort, a working list of 47 data elements frequently collected or proposed for collection regarding eligibility, enrollment, encounters and claims in the United States was prepared (see appendix B). Georgia State University, Maria Redona Couper D'Angelo, B.S., M.S. The NCVHS recognizes the vital importance of maintaining confidentiality and emphasizes that any public use of a unique identifier should be in an encrypted form. Department of Health and Human Services, Cheryl Beversdorf This recommendation is in accord with the 1992 UHDDS and the UACDS, as well as recommendations by the NCVHS Subcommittee on State and Community Health Statistics. 20. Grouping of similar services provided on different dates, as is often the case under batch billing, can be problematic if specificity of data elements is lost; the objective is to encourage identifying a unique date of record for each encounter. Race and ethnicity B. In addition, home address will allow the application of GIS (Geographic Information Systems) technology to the analysis of health issues. Department of Veterans Affairs, Assistant Secretary for Policy and Planning, Mary Dufour Type of Facility/Place of Encounter. Work has been undertaken in the past to try to bring some semblance of order to selected areas of health data collection, especially in the areas of hospital inpatients and physician office visits. With the use of UHDDS-defined data, for example, state and private abstracting systems have been providing comparable state and local data for health planners for many years. National Institute of Health, Carl E. Hendricks, Lieutenant Col., MS The Committee recommends the following actions specifically related to the core data elements: 3. The set includes reasons for the encounter, living arrangements, and marital status. Minnesota Department of Health, Trish Riley The Uniform Ambulatory Care Data Set (UACDS) regulates the area of ambulatory care. The Committee recommends that the HCFA identifier be adopted when completed. American Association of Retired Persons, Peg Douglas offices, the location of the usual or principal place of practice should be given. The site is secure. Type of admission C. Gender D. Reason for encounter D. Reason for encounter What is the purpose of data mapping A. Diagnosis Chiefly Responsible for Services Provided (outpatient) - The diagnosis, condition, problem, or the reason for encounter/visit chiefly responsible for the services provided. Dept. These comparisons also included consideration of the general availability, reliability, validity, and utility of data elements. Additionally, too frequent modification of items or definitions will cause confusion, overlapping data definitions in a single data year, and add to the burden of the facility or organization. Half of the ten major employers who were asked to participate declined; only four actually sent in a data set. HHS, NID, Division of Epikdemiology and Prevention Research, William J. Sobaski, M.B.A. AHCPR compared the 12 systems with the UB-92 and monitored deviations at 3 levels - easy, moderately difficult, and difficult to correct problems. 13. 29. Current or Most Recent Occupation and Industry, 28. The type of data collected in each different facility's patient health records is established by required standards or regulations. Office of Statewide Health Planning and Development. Seven confirmatory data items (including SSN) should also be collected when possible. Health Resources amd Services Adm. Debra A. Cerha, Lt Col, USAF,MSC Refer the core health data elements recommendations to the National Uniform Claim Committee for their consideration as they study the issue of uniform data elements for paper and electronic collection in Fall 1996. The process for these specialized areas is ongoing and final recommendations for specific elements have not yet been submitted to the full Committee. Thus, the NCVHS was the natural locus of the continuing efforts of DHHS to investigate the further standardization of health data. The data sets promulgated by the NCVHS have become de facto standards in their areas for data collection by Federal and state agencies, as well as public and private data abstracting organizations. A. The University of Illinois at Chicago, Eunice Chee Agency for Health Care Policy and Research, Simon P. Cohn, M.D., M.P.H. There is already consensus among data collectors and users for a significant number of data elements, especially elements related to person descriptors and to selected information on inpatient and ambulatory encounters. Office of Inspector General. Initial enumeration by HCFA will focus on individual providers covered by Medicare and Medicaid; however, the system will enable enumeration of other health care practitioners, as identified by system users. National Center for Health Statistics, Richard Rubin 39. Participants in the various meetings had discussed ways to disseminate new data items, seek input, and inform data collectors of recommended elements and definitions. Producing the compendium was a much more involved effort than was originally envisioned, and probably is representative of problems to be overcome in the future when standardization implementation is planned. American Society of Ophthaimic Registered Nurses. The Committee works closely with the National Center for Health Statistics, the Agency for Health Care Policy and Research, and the Health Care Financing Administration (HCFA). Blue Cross of California, Health Policy and Analysis, William J. Hayden, DDS, MPH Information on all patient problems and diagnoses requiring attention at the encounter are needed to assess the quality of care delivered, to determine what types of health problems are being seen and treated in the different types of ambulatory care facilities, and for assessing the appropriateness of the setting used to perform the services. C.Child Rural Health Advocacy Institute, Kevin Donnellan American Hospital Association, Dawn Carlson, Ph.D. The identification, definition, and implementation of standardized data in the health care and health care information fields are long overdue. Abbreviation is mostly used in categories: Health Flashcard Care Medical Technology. Items shown below with an asterisk (*) indicate that this type of information can be obtained from linking the NPI with the National Provider File and may not need separate collection. The UHDDS and UACDS have recommended the collection of all charges for procedures and services rendered to the patient during a hospitalization or encounter. Uniform Ambulatory Care Data Set. Gender As recommended by the UHDDS and the UACDS. Provide stable resources to the project to establish an interagency work group, with DHSS taking the lead, to work with the key standards-setting organizations in the area of core health data elements. An example of this could be NAHDO which could undertake to work with its members. Over three dozen data sets were studied, among them two nationally approved data sets, the Mental Health Statistics Improvement Program Data Set MHSIP) and The Adoption and Foster Care Analysis and Reporting System (AFCARS) data set. Operative Report PREOPERATIVE DIAGNOSIS: Obstruction of the rectum in a patient with known colon cancer POSTOPERATIVE DIAGNOSIS: Obstruction of the rectum due to. Health Resources and Services Administration, William E. Flynn, III Biometrics, Center for Devices and Radiological Health, Food and Drug Adm. Elizabeth Grossman Consensus has been reached on definitions for the majority of these elements; for others, there is much agreement, but definitions must still be finalized; and for a third group, additional study and testing are needed. If you continue to use this site we will assume that you are happy with it. It is recommended that convergence of these guidelines be investigated. C.Discharged/transferred to skilled nursing facility (SNF) Association of State and Territorial Health Officials, D. Walter Biggs, III However, for services billed on a batch basis, two dates would be required to encompass the range of dates from the beginning of all treatments included under the batch (global) code to the end, with a check box to indicate that this is a batch-based encounter. 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